Alert

Recognition of Retained Foreign Body - Button Battery

Patient Safety Alert

Resultant harm to the patient

A patient required surgery for removal of a retained button battery, which required subsequent surgeries to repair esophageal damage.

Actions to mitigate risk of similar harm at your hospital

Order a low dose radiation “scout” film prior to a patient receiving barium for a swallow study

Develop practice guidelines/pathway that prompts providers to consider a foreign body as the cause for acute dysphagia for GI, Radiology, Respiratory Therapy, General Pediatrics/Hospitalist, Surgery, and Speech Pathology

Develop a clear definition of “critical result” (e.g., swallowing evaluation) and process of reporting critical results from all ancillary tests to providers in your EMR

Include “foreign body,” especially including button batteries, in the EMR Well Child Checklist for young patients (under 5) and during well-child visits in the ambulatory setting

Raise public awareness through the dissemination of information about harm related to the ingestion of a button battery

Develop standard work instructions and a clear process for consulting providers to escalate patient care concerns, recommendations, and any critical results to the primary care provider

Target audiences

Quality

Patient Safety

Legal/Risk Management

Cause Analysis Staff

Organizational Leaders

Radiology

Speech Pathology

ENT Services

Gastroenterology Services

Respiratory Therapy

After Hours Nursing Triage

Primary Care

Emergency/Urgent Care

Fundamental issue

Ingested button batteries remain conductive and can cause tissue erosion and significant damage if not removed in a timely manner. A deviation in practice resulted in a failure to recognize a retained button battery in a patient’s esophagus. Providers did not consider ingestion of a foreign object as a possible cause of the patient’s acute dysphagia with solid foods.

There was a lack of communication among the providers, and, even though patient care information was available to providers, critical concerns were neither highlighted nor prioritized. Closed-loop communication was not used to verify receipt of the results of the swallowing evaluation and the pathologist’s concerns by the provider.